胃癌的淋巴结分组。
NO.1－贲门右淋巴结。
NO.2－贲门左淋巴结。
NO.3－胃小弯淋巴结。
NO.4sa－胃短血管淋巴结。
NO.4sb－胃网膜左血管淋巴结。
NO.4d－胃网膜右血管淋巴结。
NO.5－幽门上淋巴结。
NO.6－幽门下淋巴结。
NO.7－胃左动脉淋巴结。
NO.8a－肝总动脉前淋巴结。
NO.8p－肝总动脉后淋巴结。
NO.9－腹腔干淋巴结。
NO.10－脾门淋巴结。
NO.11p－脾动脉近端淋巴结。
NO.11d－脾动脉远端淋巴结。
NO.12a－肝十二指肠韧带内沿肝动脉淋巴结。
NO.12b－肝十二指肠韧带内沿胆管淋巴结。
NO.12p－肝十二指肠韧带内沿门静脉后淋巴结。
NO.13－胰头后淋巴结。
NO.14v－肠系膜上静脉淋巴结。
NO.14a－肠系膜上动脉淋巴结。
NO.15－结肠中血管淋巴结。
NO.16a1－主动脉裂孔淋巴结。
NO.16a2－腹腔干上缘至左肾静脉下缘之间腹主动周围脉淋巴结。
NO.16b1－左肾静脉下缘至肠系膜下动脉上缘之间腹主动脉周围淋巴结。
NO.16b2－肠系膜下动脉上缘至腹主动脉分叉之间腹主动脉周围淋巴结。
NO.17－胰头前淋巴结。
NO.18－胰腺下缘淋巴结。
NO.19－膈下淋巴结。
NO.20－膈肌食管裂孔淋巴结。
NO.110－下胸部食管旁淋巴结。
NO.111－膈上淋巴结。
NO.112－中纵膈后淋巴结
李国新教授论文中的淋巴结清扫顺序Dissection：
Perigastric LNs in D2 LDG were partitioned into six areas
1. Lower left area (No. 4sb, 4d LNs along the left and right gastroepiploic vessels);
2. lower right area (No. 14v LNs along the superior mesenteric vein, No. 6 LNs infrapyloric and around the origin of the right gastroepiploic vessels);
3. upper right area (No. 5 LNs suprapyloric, No.12a LNs along the proper hepatic artery in the hepatoduodenal ligament);
4. central area posterior to the gastric body (No. 7,8a, 9, 11p LNs along the celiac artery and its three main branches);
5. area between liver and stomach (No. 1, 3, 5 LNs along the lesser curvature).
6. Observations on the topography of perigastric structures, especially pancreas and peripancrea-tic spaces, were carried out in live surgery andalso by review of video records.
All dissections were successfully performed in peripancreatic spaces and their extensions. Gastric vessels were located by special landmarks, traced along vascular trunks and and bifurcations, and identi?ed by ?ne dissection technique in the vagina vasorum.
所有的清扫过程均在胰腺周围间隙及其拓展平面内进行。胃血管的定位依靠解剖学标志、上下级血管及血管鞘内清扫技术完成。
这句话中的“间隙、标志、上下级血管、血管鞘”是关键词。下面的内容会不时提及。
注意：所谓的血管鞘内清扫在国内外仍存在争议，支持者认为鞘内清扫方便、干净，反对者担心因此形成的神经损伤、淋巴漏等。
血管鞘是个什么东东在后面会详细讲解，现在做个标记。
Dividing the gastrocolic ligament and getting access to prepancreatic space
The gastrocolic ligament (GCL) was divided along its adhesion zone on the transverse colon. The greater omentum was placed between liver and stomach to expose the space between the anterior and posterior leaves of the transverse mesocolon. Dissection was continued cephalad in the prepancreatic space by dissecting the pancreatic capsule off the pancreatic parenchyma.
将胃结肠韧带自横结肠系膜上游离下来，向头侧直到将胰腺包膜自胰腺实质上游离下来。
这里要强调大网膜后叶和横结肠系膜的关系(内容源自格雷临床解剖学）：
The posterior sheet is adherent to the transverse mesocolon at its root and is often known as the gastrocolic ligament,which is the supracolic part of the greater omentum.In early fetal life the greater omentum and transverse mesocolon are separate structures,and this arrangement sometimes persists.During surgical mobilization of the transverse colon,the plane between the transverse mesocolon and greater omentum can be entered oppsite the taenia omentalis,and the greater omentum can be separated entirely from the transverse colon and mesocolon if required.Access into the lesser sac can be obtained via this approach if the upper part of the posterior sheet of the greater omentum is then divided.This gives a relatively bloodless plane of entry for surgical access to the posterior wall of the stomach and to the anterior surface of the pancrease.大意是说大网膜后叶在与横结肠系膜粘连在一起，在婴儿早期这两个结构还是独立的，但是以后可能愈着在一起。但是手术需要的时候仍然可以分开。下面两个图将显示这个变化。
大网膜后叶和横结肠尚未愈着
大网膜后叶和横结肠完成愈着。
相关疾病：
头痛Lymph node dissection in lower left area
The pancreas tail and splenic hilum were exposed by tensioning the gastrosplenic ligament (GSL) and by traction of the gastric fundus. The left gastroepiploic artery (LGeA) and two to three short gastric vessels (SGV) were divided. The great omentum was dissected off the greater curvature right to the junction between gastric body and antrum, with No. 4sb, 4d LNs resected (Figure 2).
这里说下脾脏的解剖。脾脏位于左上腹部，由胃脾韧带、脾肾韧带、膈结肠韧带固定。胃脾韧带在胃大弯和脾门之间，与大网膜左侧相连续。胃脾韧带的两层先分开包绕脾脏，再靠近形成脾肾韧带和膈结肠韧带。脾肾韧带自脾脏延续至后腹壁；膈结肠韧带延续到前外侧腹壁。脾肾韧带由两层腹膜组成：小网膜的后壁向外侧与脾肾韧带前层相延续，覆盖左肾，到达脾门后与胃脾韧带的后曾相延续；脾肾韧带的后层向外侧与膈下表面腹膜延续，延伸到脾脏表面肾压迹。脾脏血管走形在脾肾韧带的两层腹膜之间：胰尾经常出现在脾脏下部分。胃脾韧带也有两层，后层与脾门及胃后壁的腹膜相延续；前层由脾脏胃压迹的腹膜反折而来，与胃前面的腹膜相延续。胃短血管和胃网膜左血管均走形在胃脾韧带的两层腹膜结构中。膈结肠韧带自结肠脾区延伸至11肋水平的膈表面，向下向外延伸，与胰尾部横结肠系膜外侧相延续，与脾门的脾肾韧带相延续。The phrenicocolic ligament extends from the splenic flexure of the colon to the diaphram at the level of the eleventh rib.It extends inferiorly and laterally and is continuous with the peritoneum of the lateral end of the transverse mesocolon at the lateral margin of the lateral margin of the pancreatic tail,and the splenorenal ligament at the hilum of the spleen.
在脾脏下外极靠近胃大弯的部位，经常会有“扇形的皱襞”自胃脾韧带的前面延续下来，与膈结肠韧带融合。A fan-shaped preplenic fold frequently extends from the anterior aspect of the gastrosplenic ligament near the greater curvature of the stomach below the inferolateral pole of the spleen and blends with the phrenicocolic ligament.
（以上内容出自格雷临床解剖学，因为打字太累，所以仅把比较麻烦的地方写上原文）
总之：在理解了大网膜和横结肠系膜的关系后，脾脏的韧带与周围组织的关系非常令人头痛，且相关图片较少，希望高手指点！！！
贴上一些图片，抛砖引玉。
图中红色墨水标记的地方是否就是上文中的“扇形皱襞A fan-shaped preplenic fold ”？？？？
以下内容来自南方微创论坛张策讲课内容：胃网膜左血管
定位：胰腺尾部上缘 因为胃网膜左血管起自脾动脉的第三段或第四段，以第三段居多，所以在胰尾上缘。
胰前间隙 脾动脉分为胰上段，胰后段，胰前段，门前段。脾动脉第三段是胰前段，所以是胰前间隙。在胰前间隙找脾动脉主干，找到胃网膜左血管。
注意：部分脾下极血管与胃网膜左动脉共干，形成脾胃网膜干，结扎胃网膜左动脉需在脾胃网膜干分叉后。
继续脾脏韧带
0Lymph node dissection in the lower right area
Dissection was continued along the fusion line between the posterior wall of the gastric antrum and the transverse mesocolon. The mesogastrium was dissected off the mesocolon until the pancreas head and the duodenum were exposed. The superior mesenteric vein (SMV) was dissected at the inferior margin of the pancreas neck to resect No. 14v LNs. The right gastroepiploic vein (RGeV) was divided at its origin on the SMV, proximal to the origin of the
anterior superior pancreatoduodenal vein (Figure 3) to dissect No. 6 LNs.
将粘连在胃窦的横结肠系膜游离下来，直至胰头和十二指肠被完全显露。现在14V已经没必要清扫了，这里比较重要的血管是胃网膜右静脉和胃网膜右动脉。
下面内容来自南方微创论坛张策讲课内容：
胃网膜右静脉 走形于胰前间隙，多汇入胃结肠干。胰切迹右缘是胃结肠干解剖学标志。所以胃网膜右静脉间隙是胰前间隙，上级血管是胃结肠干，标志是胰切迹右缘。掀起胃窦网膜侧， 书上说横结肠系膜在胰十二指肠前面形成系膜根，但实际上大部分情况还要往上粘连，同胃窦粘连，部分病人甚至粘连到胃小弯，所以要在结肠系膜及胃系膜之间的平面慢慢游离，充分暴露胃系膜及结肠系膜后方可充分显露胃结肠干血管，找到胃网膜右静脉。
胃结肠干的变化：1、胃结肠干包括胃网膜右静脉/上右结肠静脉/胰十二指肠上静脉，经典3干约占50%。2、3支合干，上右结肠静脉/胃网膜右静脉/中结肠静脉。3、胃网膜右静脉与中结肠静脉。4、三支血管没有合干，分别汇入肠系膜上静脉。
胃结肠干定位：肠系膜上静脉越过胰腺钩突前面，汇入胰颈后面时接受胃结肠干汇入。钩突/胰头/胰颈形成胰腺切迹，在胰切迹右缘找到胃结肠干。间隙是横结肠后间隙（我觉得胃结肠干的位置在横结肠系膜前层和大网膜后叶后层反折处，只需要打开一层腹膜即可找到胃结肠干，在大网膜的两层之间找到胃网膜右静脉，在横结肠系膜两层之间找到结肠中静脉及右结肠静脉，下面发张图，大家看下就可以明白了）横结肠系膜自十二指肠降部开始覆盖到这里。横结肠系膜与十二指肠间形成间隙，将横结肠系膜从十二指肠充分游离出来后才能显露胃结肠干。
胃网膜右动脉的上级血管是胃十二指肠动脉。胃十二指肠动脉在胃窦与胰头之间，张力将胃窦向头侧掀起，有个胃窦胰头间沟，沟内可找到胃十二指肠动脉，位置恒定。
下图示胃肠道的血管总是走形在两层腹膜的包夹中间。
下图显示胃网膜右血管与胰十二指肠上血管汇合。
下图显示胃网膜右动脉起自胃十二指肠动脉。
Lymph node dissection in the upper right area
The gastroduodenal artery (GDA) was dissected upward in the prepancreatic space (PPS) (Figure 4) and was traced to locate the common hepatic artery (CHA) at the superior margin of the pancreas neck (Figure 5), with the posterior wall of the the duodenal bulb mobilized. No. 12a LNs was dissected along the vagina vasorum of the proper hepatic artery (PHA) in the hepatoduodenal ligament (HDL). No. 5 LNs were dissected by dividing the right gastric artery (RGA).
胃右动脉、肝固有动脉、肝总动脉以及后面的脾动脉、胃左动脉均可以胃十二指肠动脉顺藤摸瓜得到。
注意：肝总动脉位于腹后壁，网膜囊的后壁。肝总动脉经常迂曲，顶起网膜囊的后壁，形成肝胰襞。腹腔干的三大分支多数在胰后间隙走形。
图片显示胃十二指肠动脉与上下级血管的关系。
Lymph node dissection centrally
The gastropancreatic fold was tensioned by contertraction of the gastric body upward and the pancreas downward. The celiac artery (CA) and its main branches, i.e., the common hepatic artery and the splenic artery, were dissected in the retropancreatic space (RPS) at the superior margin of the pancreas body, with No. 9, 8, 11p LNs dissected (Figure 6). The left gastric artery (LGA) was divided with No. 7 LNs dissected (Figure 7).
脾动脉 有很多形态学的变化。定位：胰体上缘。腹腔干发出脾动脉后在胰体上缘的胰后间隙走形。沿着肝总动脉向左解剖或找到胃左动脉后找到腹腔干，然后向左继续摸索。
胃左静脉 与胃左动脉不同，胃左静脉走形变异较大，可分为升段、中段、降段，可汇入门静脉、脾静脉、门脾角或者少部分汇入肠系膜下静脉。
定位：胰腺颈部和胰腺体部的交界处有个粗隆称为网膜粗隆，是胰腺颈部和胰腺体部的隆起，在隆起后方就是腹腔干。助手将胃及其系膜向腹侧牵引可悬吊起胰腺，即吊起腹腔干，即可找到胃左静脉。网膜粗隆和胃胰襞是胃左血管的标志。属于胰后间隙。
通过这张图大致可以理解“助手将胃及其系膜向腹侧牵引可悬吊起胰腺，即吊起腹腔干”这句话。
Lymph node dissection between liver and stomach
The hepatogastric ligament and the anterior leaf of the hepatoduodenal ligament were tensioned and divided by contertraction of the liver upward and the gastric body downward. The lesser curvature was dissectedupward off the lesser curvature to the gastric cardia with No. 1, 3, 5 LNs dissected。
到这里淋巴结清扫基本结束了。
既然已经清楚清扫的步骤，下面我们要了解下我们到底切除了哪些东西，切除的东西的范围是什么。
没有人看，算了，学习的最高境界在于取悦自己。
那么我们到底切除了哪些东西，切除的东西的范围是什么呢？？
有胚胎学基础且看过几台胃癌根治术的人不难理解下面这句话：
全胃癌根治术其实是保留肝胆胰脾及食管以上结构的前肠切除术。
为了保证根治性切除，我们除了切除胃本身，还需要尽可能切除它的系膜及系膜内结构，这就是“淋巴结清扫”。
现在我们要做的就是复习胚胎学（以下内容是张策医生讲课内容，因为没有他本人的课件，所以我自己在其他地方找了一堆图片，帮助大家理解）：
在胚胎发育4周前，体腔是个圆桶，胃肠悬吊在体腔中心。在前肠的一段通过腹侧与背侧系膜悬吊。但成人后却不再如此。如何变化的呢？因为胃肠系膜生长速度不同（腹侧系膜有肝脏原基，背侧系膜有脾芽，根部有胰腺原基，）腹侧上皮生长慢，背侧上皮生长快，前肠弯曲，形成胃小弯和胃大弯，但此时仍保持在矢状位。随着背侧系膜的生长，胃发生折叠，导致小弯向右，大弯向左。在腹侧系膜肝胃之间形成小网膜；肝与膈肌之间形成镰状韧带；在背侧系膜发生折叠，脾胃之间形成胃脾韧带，脾与腹壁之间形成脾肾韧带或称脾膈韧带，在前肠系膜根部是胰腺。系膜折叠后逐渐愈着在腹壁上。
下图显示胚胎早期的前肠/中肠/后肠等结构，腹侧胰腺原基及背侧胰腺原基也可以看到。
0下面的图片ABC显示腹侧系膜及背侧系膜生长速度不等，图B出现了胃小弯和胃大弯，但此时仍保持在矢状位；图C显示胃及其系膜发生折叠，导致小弯向右，大弯向左。
0下图显示的是胰腺及肝外胆管的胚胎学变化，可以协助上图理解胃及其系膜的折叠。
以下两张图显示中肠的发生发展。
下图显示十二指肠与背腹侧系膜的关系。
下图显示背腹侧系膜的发展及其内器官的发展变化。
下图显示胃的折叠过程。这里可以在此看到大网膜及横结肠系膜之间的关系，图中表示大网膜及横结肠系膜融合了，但是，我们仍要记住那句话，术中需要，可以沿着他们之间的间隙在此将他们分离。
下面这张图是对张策医生上面一段话的完美诠释，简单明了。
先说说前肠的腹侧系膜。前肠的腹侧系膜形成了小网膜。小网膜包括肝胃韧带和肝十二指肠韧带。肝胃韧带分为前层和后层，越过食管腹段的前面变成胃膈韧带的左层，肝胃韧带的后层变成胃膈韧带的右层。胃膈韧带将食管腹段压在右膈脚前方。胃膈韧带左层和右层之间，靠近膈脚地方有个裸区。
下面我们看一下格雷临床解剖怎么说的：
The lesser omentum is formed of two layers of peritoneum separated by a variable amount of connective tissue and is derived from the ventral mesogastrium. It runs from the inferior visceral surface of the liver to the abdominal oesophagus, stomach, pylorus and first part of the duodenum. Superiorly, its attachment to the inferior surface of the liver forms an L-shape. The vertical component of the L is formed by the fissure for the ligamentum venosum. Inferiorly, the attachment turns and runs horizontally to complete the L in the portal fissure. The vertical and horizontal components of the lesser omentum run between the liver and the stomach and duodenum and are known as the gastrohepatic and hepatoduodenal ligaments, respectively. At the lesser curvature of the stomach, the layers of the lesser omentum split to enclose the stomach and are continuous with the visceral peritoneum covering the anterior and posterior surfaces of the stomach. The anterior layer of the lesser omentum descends from the fissure for the ligamentum venosum onto the anterior surface of the abdominal oesophagus, stomach and duodenum. The posterior layer descends from the posterior part of the fissure for the ligamentum venosum and runs onto the posterior surface of the stomach and pylorus. The lesser omentum forms the anterior surface of the lesser sac. The gastrohepatic ligament contains the right and left gastric vessels, branches of the vagus nerves, and gastrohepatic lymph nodes between its two layers near their attachment to the stomach. The right lateral border of the lesser omentum is thickened and extends from the junction between the first and second parts of the duodenum to the porta hepatis. This border is free and forms the anterior wall of the epiploic foramen. It contains the portal vein, common bile duct, hepatic artery, portocaval lymph nodes and lymphatics and the hepatic plexus of nerves ensheathed in a perivascular fibrous capsule. Occasionally the free margin extends to the right of the epiploic foramen, runs to the gallbladder and is referred to as the cystoduodenal ligament.
The left border of the lesser omentum is short and runs over the inferior surface of the diaphragm between the liver and medial aspect of the abdominal oesophagus. The lesser omentum is thinner on the left and may be fenestrated or incomplete: the variations in thickness are dependent upon the amount of connective tissue, especially fat.
下面一张图可以看到小网膜的后层范围。
下面一张图显示小网膜的上界。小网膜连接到肝脏的下面形成了一个L形，L形的垂直部分是肝脏静脉韧带，水平部分是肝脏的门静脉裂。 It attachments to the inferior surface of the liver forms an L-shape. The vertical component of the L is formed by the fissure for the ligamentum venosum. Inferiorly, the attachment turns and runs horizontally to complete the L in the portal fissure.
下图显示胃膈韧带，没有找到胃膈韧带与胃的系膜相延续的图，大家结合本节第一张图片想象吧：肝胃韧带分为前层和后层，越过食管腹段的前面变成胃膈韧带的左层，肝胃韧带的后层变成胃膈韧带的右层。
前肠的背侧系膜。前肠背侧系膜即大网膜，分为前层和后层，前层自胃大弯/十二指肠第一段向下悬垂，后层固定于后腹壁。前层包括胃膈韧带，胃脾韧带，胃结肠韧带，还有悬垂的大网膜，都属于广义的大网膜。后层固定的部分以胰腺为界，胰前的叫作胰前筋膜，胰后叫作胰后筋膜。在两层筋膜间有胰腺实质和前肠的所有血管。胰腺上缘，前叶和后叶合并起来，形成脾肾韧带/脾膈韧带。胰前筋膜和胰后筋膜是原始系膜表面的腹膜。在胰后筋膜后方形成胰十二指肠后间隙和各种各样的间隙相互贯通。广义的大网膜和横结肠系膜之间形成系膜间间隙。
看看格雷临床解剖学的说法：
The greater omentum is the largest peritoneal fold and hangs inferiorly from the greater curvature of the stomach. It is a double sheet: each sheet consists of two layers of peritoneum separated by a scant amount of connective tissue. The two sheets are folded back on themselves and are firmly adherent to each other. The anterior sheet descends from the greater curvature of the stomach and first part of the duodenum. The most anterior layer is continuous with the visceral peritoneum over the anterior surface of the stomach and duodenum and the posterior layer is continuous with the peritoneum over the posterior wall of the stomach and pylorus. The anterior sheet descends a variable distance into the peritoneal cavity and then turns sharply on itself to ascend as the posterior sheet. The posterior sheet passes anterior to the transverse colon and transverse mesocolon. It is attached to the posterior abdominal wall above the origin of the small intestinal mesentery and anterior to the head and body of the pancreas. The anterior layer of the posterior sheet is continuous with the peritoneum of the posterior wall of the lesser sac. The posterior layer is reflected sharply inferiorly and is continuous with the anterior layer of the transverse mesocolon. The posterior sheet is adherent to the transverse mesocolon at its root and is often known as the gastrocolic ligament, which is the supracolic part of the greater omentum. In early fetal life the greater omentum and transverse mesocolon are separate structures, and this arrangement sometimes persists. During surgical mobilization of the transverse colon, the plane between the transverse mesocolon and greater omentum can be entered opposite the taenia omentalis, and the greater omentum can be separated entirely from the transverse colon and mesocolon if required. Access into the lesser sac can be obtained via this approach if the upper part of the posterior sheet of the greater omentum is then divided. This gives a relatively bloodless plane of entry for surgical access to the posterior wall of the stomach and to the anterior surface of the pancreas. The greater omentum is continuous with the gastrosplenic ligament on the left, and on the right it extends to the start of the duodenum. A fold of peritoneum, the hepatocolic ligament, may run from either the inferior surface of the right lobe of the liver or the first part of the duodenum to the right side of the greater omentum or hepatic flexure of the colon.
前肠的背侧系膜。前肠背侧系膜即大网膜，分为前层和后层，前层自胃大弯/十二指肠第一段向下悬垂，后层固定于后腹壁。前层包括胃膈韧带，胃脾韧带，胃结肠韧带，还有悬垂的大网膜，都属于广义的大网膜。后层固定的部分以胰腺为界，胰前的叫作胰前筋膜，胰后叫作胰后筋膜。在两层筋膜间有胰腺实质和前肠的所有血管。胰腺上缘，前叶和后叶合并起来，形成脾肾韧带/脾膈韧带。胰前筋膜和胰后筋膜是原始系膜表面的腹膜。在胰后筋膜后方形成胰十二指肠后间隙和各种各样的间隙相互贯通。广义的大网膜和横结肠系膜之间形成系膜间间隙。
看看格雷临床解剖学的说法：
The greater omentum is the largest peritoneal fold and hangs inferiorly from the greater curvature of the stomach. It is a double sheet: each sheet consists of two layers of peritoneum separated by a scant amount of connective tissue. The two sheets are folded back on themselves and are firmly adherent to each other. The anterior sheet descends from the greater curvature of the stomach and first part of the duodenum. The most anterior layer is continuous with the visceral peritoneum over the anterior surface of the stomach and duodenum and the posterior layer is continuous with the peritoneum over the posterior wall of the stomach and pylorus. The anterior sheet descends a variable distance into the peritoneal cavity and then turns sharply on itself to ascend as the posterior sheet. The posterior sheet passes anterior to the transverse colon and transverse mesocolon. It is attached to the posterior abdominal wall above the origin of the small intestinal mesentery and anterior to the head and body of the pancreas. The anterior layer of the posterior sheet is continuous with the peritoneum of the posterior wall of the lesser sac. The posterior layer is reflected sharply inferiorly and is continuous with the anterior layer of the transverse mesocolon. The posterior sheet is adherent to the transverse mesocolon at its root and is often known as the gastrocolic ligament, which is the supracolic part of the greater omentum. In early fetal life the greater omentum and transverse mesocolon are separate structures, and this arrangement sometimes persists. During surgical mobilization of the transverse colon, the plane between the transverse mesocolon and greater omentum can be entered opposite the taenia omentalis, and the greater omentum can be separated entirely from the transverse colon and mesocolon if required. Access into the lesser sac can be obtained via this approach if the upper part of the posterior sheet of the greater omentum is then divided. This gives a relatively bloodless plane of entry for surgical access to the posterior wall of the stomach and to the anterior surface of the pancreas. The greater omentum is continuous with the gastrosplenic ligament on the left, and on the right it extends to the start of the duodenum. A fold of peritoneum, the hepatocolic ligament, may run from either the inferior surface of the right lobe of the liver or the first part of the duodenum to the right side of the greater omentum or hepatic flexure of the colon.
前肠系膜和腹壁之间发生的关系：前肠包括食管及以上段消化道/胃/大网膜附着之前的十二指肠段/背胰等。背胰与腹后壁发生愈着就形成胰十二指肠后间隙，前肠系膜折叠形成胃后间隙。搞明白了胚胎学，将胰十二指肠复原为胚胎状态，就可以知道间隙在哪里，就能够知道手术平面在哪里。横结肠倒在胰十二指肠下缘，形成横结肠系膜根和横结肠后间隙。然后胃的大网膜盖在横结肠系膜的上面，形成胃结肠系膜之间的间隙。3版外科手术学表述为胃的手术在横结肠系膜两叶之间做，实际上是在胃系膜和横结肠系膜之间做，因为在横结肠前后叶之间做，横结肠的血管全部被裸露了。
这张图显示横结肠系膜和大网膜的关系。横结肠系膜先贴在胰十二指肠下缘，大网膜再覆盖在横结肠系膜上面，但是他们之间仍然为外科手术保留了间隙。
下图说明横结肠血管走形在横结肠系膜内，所以胃癌手术第一步不是沿着横结肠边缘将大网膜及横结肠系膜前叶剥离，而是沿着横结肠系膜及大网膜之间的间隙剥离，不然横结肠的血管全部被裸露啦，手术风险就会飙升。不过有个问题：肿瘤细胞的转移是否会因为大网膜和横结肠系膜的紧密关系而特别容易转移到横结肠系膜前叶呢？切除横结肠系膜前叶对预后是否有益呢？？等大佬们回答吧。
加关注随着胃肠系膜发生演变，原始胃肠及其系膜与体壁之间、系膜与器官之间、系膜与系膜之间发生愈着，而愈着过程形成了由腹膜融合蜕变形成的疏松结缔组织。张策老师将这些疏松结缔组织的潜在间隙成为融合筋膜间隙。很明显，融合筋膜间隙是潜在的，无血的，可以拓展的，可以重复的。这个间隙的特点太迎合外科医生的口味了，因此将胃肠系膜从腹壁和周围血管游离下来时，最佳的间隙就是融合筋膜间隙。
融合筋膜间隙，定义是在原始胃肠发育过程中，原始胃肠及其系膜与体壁之间、系膜与器官之间、系膜与系膜之间发生愈着以后，在这些结构间所形成的由腹膜融合蜕变形成的疏松结缔组织。这些包含这些疏松结缔组织的潜间隙就是融合筋膜间隙，它符合潜在的无血的可重复的可以拓展的特点。
胃的系膜、胰十二指肠的系膜、空回肠的系膜、右结肠系膜、左结肠系膜、直肠系膜和后盆壁和前面的生殖器之间发生了融合，最后大网膜盖下来和腹壁发生了融合。这显示了胃肠系膜发生的演变过程，形成了很多融合筋膜间隙。
除外融合筋膜间隙，唯一将胃肠固定在腹壁上的结构实际上是三大血管蒂（前中后肠有三条血管，腹腔干、肠系膜上和肠系膜下），最多还加一个直肠侧韧带。1、融合筋膜间隙对于腹腔镜手术是有帮助的，是腔镜手术的天然外科平面，当时他的系膜是怎样粘在腹壁上的，我们现在就怎样将他分下来。2、我们找入路，找间隙，其实就是找融合的边界，找腹膜反折，从自然的边界分过来。
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2举报中国期刊SCI数据初评腹腔中间是胃肠系膜，周围是腹横筋膜。腹横筋膜后外侧是泌尿器官，肾脏输尿管前列腺都在那里。如果突破腹横筋膜，输尿管、骶前静脉损伤、神经损伤都来了。所以：
腹横筋膜是手术的向导。
融合筋膜间隙是胃肠手术的天然外科平面。
融合边界和自然边界是手术的入路。
血管神经淋巴蒂是融合筋膜间隙唯一不可逾越的障碍。
说说手术的入路：
1/沿着横结肠上缘向左侧解剖，直到将胃膈韧带左缘游离下来（大家保持淡定，脾脏的韧带很复杂，所谓胃膈韧带左缘，实际上是和横结肠系膜及膈结肠韧带愈着的，因此实际上是将胃膈韧带与结肠脾曲游离。）向右到达十二指肠降部的右端，此处是前肠系膜的左下方的边缘。
2/横结肠系膜根部一带，胰体下缘处。此处是前肠与中肠发生关系处。（胃结肠干是个大大的标志）
3/沿着胰腺上缘，为了解剖胃的血管（胃左动脉/胃十二指肠动脉/脾动脉/肝总动脉等等），保留胰腺。
4/胃膈韧带右层腹膜反折，是前肠背侧系膜的右缘（小网膜在这里结束使命了）。
5/小网膜上缘，将小网膜自肝脏切除（那个L形的附着处）。
复习手术过程：
1/将大网膜自横结肠系膜上游离下来，向头侧游离到胰腺下缘甚至切开胰腺筋膜游离到胰腺上缘。
2/向左侧解剖到胰尾上缘的胰前间隙，定位胃网膜左血管。
3/将横向系膜向下方松解，将胰头及十二指肠降部完全显露。将粘连在胃窦的横结肠系膜游离下来，将胰头及十二指肠降部完全显露，游离十二指肠和定位胃结肠干（胃网膜右静脉）。
4/在胃窦胰头间沟内定位胃十二指肠动脉GDA。
5/游离胃十二指肠动脉后将胰颈向下方牵引，显露胰腺上方结构包括肝总动脉和胃十二指肠的分叉门静脉等。
6/将胰体尾向尾侧牵引，暴露脾动脉。
7/腹腔干的三大分支解剖后，胰腺上缘的胃系膜尚未从腹壁上游离下来，进去将网膜囊的后壁向头侧解剖，直到膈肌脚。右膈脚的内部形成膈食管裂孔。肝胃韧带经过食管前面移行为胃膈韧带。肝胃韧带后叶移行为胃膈韧带右侧。在胃的系膜和膈肌之间，还是有间隙的。黄色的系膜和红色的膈肌纤维之间有个边界。黄红交界即黄色的系膜和膈肌纤维之间的交界。
总结：胃的手术包括：1/从周围结构中游离胃的系膜；2/离断胃的血管；3/将断了血管的游离的系膜从前肠剜除，即将脾脏肝脏胰腺等前肠结构保留，其他切除。
1/从周围结构中游离胃的系膜，需要进入胃后间隙/大网膜和横结肠系膜之间的间隙/横结肠后间隙（解剖胃结肠干）。如果解剖肠系膜上静脉和门静脉还需进入胰十二指肠后间隙。
2/解剖胃的主要血管。胃的主要血管都要经过胰腺走形，都在系膜内走形，包括胰前间隙/胰后间隙/肝十二指肠韧带内的间隙。
3/保留脾脏肝脏胰腺等结构的前肠切除术，进入网膜囊，切断胃脾韧带，切断肝胃韧带。
前肠器官所有的营养血管都经过胰腺到达靶器官，导致胰腺成为血管的中心及标志。
胰尾上缘定位胃网膜左血管。
胰体下缘定位肠系膜上静脉。
胰切迹右缘定位胃结肠干及胃网膜右静脉。
胰头上缘定位胃十二指肠动脉。
胰颈上缘定位门静脉及胃右动脉。
胰颈上缘找到肝胰襞定位肝总动脉。
胰体上缘定位胃左动脉。
胃血管的解剖秘诀：找标志/找间隙/顺藤摸瓜/鞘内解剖。
找间隙：胰前间隙定位胃网膜左/胃网膜右/胃十二指肠动脉
胰后间隙定位腹腔干的三分支。
胰十二指肠后间隙定位肠系膜上静脉和脾静脉。
胃后间隙定位腹腔干。
顺藤摸瓜：
胃十二指肠动脉在胃窦与胰头之间，张力将胃窦向头侧掀起，有个胃窦胰头间沟，沟内可找到胃十二指肠动脉，位置恒定。依据胃十二指肠动脉可顺序找到腹腔干三分支。
血管鞘的应用，血管鞘内光滑，鞘外有神经纤维。实际操作方便，但争议较大。争议在于：自主神经的破坏/淋巴瘘等。
胰腺是胃肠解剖的中心标志。1、胰腺是间隙枢纽。胰十二指肠这里，胃肠由各种融合形成多重叠压的融合筋膜间隙，胰后间隙和胰十二指肠后间隙，上可从胃后间隙，下可从左右结肠后间隙，上下左右前后有多重系膜间隙叠压在这里。胰十二指肠周缘形成进入这些间隙的枢纽。2、胰腺是血管中心。胰腺是前肠血管中心。胰跟中肠血管也有关系。胰腺向后倒得时候肠系膜上动脉和腹腔干中间只有1cm，导致胰腺躺在肠系膜上动脉的表面。胰和后肠血管也有些关系。肠系膜下静脉注入脾静脉时候要经过胰尾后面。3、胰腺是视觉中心。以上是普遍性。
胃外科解剖的特殊性：不像直肠系膜解剖、左右结肠系膜的解剖，因为他们的系膜直接与腹壁发生关系，基本上进入融合筋膜间隙就能做完手术。胃除了和腹壁、周围血管发生关系时要用到融合筋膜间隙，胃是在系膜内扣东西，在系膜内解剖。所以系膜内间隙更重要。胃的切除是切除前肠的一部分，所以胃主要血管的解剖大多是在前肠系膜内完成的，而不是在融合筋膜间隙内完成。所以胃外科的特殊性是系膜内间隙更重要。
